Introduction

Obesity is the excessive or abnormal accumulation of fat or adipose tissue in the body that may impair health. Obesity has become an epidemic which has worsened for the last 50 years. In the United States, the economic burden is estimated to be about $100 billion annually. Obesity is a complex disease and has multifactorial etiology. It is the second most common cause of preventable death after smoking. Obesity is associated with multiple medical conditions and can cause serious complications of chronic conditions. Obesity needs multiprong treatment strategies and may require lifelong treatment. A 5% to 10% weight loss can significantly improve health, quality of life, and economic burden of an individual and a country as a whole.[1][2][3][4][5]

Etiology

Obesity is the result of an imbalance between daily energy intake and energy expenditure resulting in excessive weight gain. Obesity is caused by multiple factors which can be genetic, cultural, and societal can be considered common. Other causes of obesity include reduced physical activity, insomnia, food habits, endocrine disorders, medications, food advertisements, and energy metabolism.

Most common syndromes associated with obesity include Prader Willi syndrome and MC4R syndromes, others like fragile X, Bardet-Beidl syndrome, Wilson Turner congenital leptin deficiency, and Alstrom syndrome are also associated with obesity.

Epidemiology

Nearly one-third of adults and about 17% of adolescents in the United States are obese. According to Center for Disease Control and Prevention (CDC), 2011 to 2012 data, one out of five adolescents, one out of six elementary school age children, and one out of 12 preschool age children are obese. Obesity is more prevalent in African Americans, followed by Hispanics and whites. Southern US states have the highest prevalence, followed by the Midwest, Northeast and the west.

Obesity can cause increased fatty acid deposition in the myocardium causing left ventricular dysfunction. It has also been shown to alter renin-angiotensin system causing increasing salt retention and elevated blood pressure.

Adipocytes have been shown to have an inflammatory and prothrombotic activity which can increase the risk of strokes.

History and Physical

All children six years and older, adolescents, and all adults should be screened for obesity according to the United States Preventative Services Task Force (USPSTF) recommendations.

Physicians should carefully screen for underlying causes contributing to obesity. A complete history should include:

Evaluation

A standard screening tool for obesity is the measurement of body mass index (BMI). BMI is calculated using weight in kilograms divided by the square of height in meters.[6][7][8][9][10] Obesity can be classified according to BMI:

Underweight: less than 18.5 kg/m2

Normal range: 18.5 kg/m2 to 24.9 kg/m2

Overweight: 25 kg/m2 to 29.9 kg/m2

Obese, Class I: 30 kg/m2 to 34.9 kg/m2

Obese, Class II: 35 kg/m2 to 39.9 kg/m2

Obese, Class III: more than 40 kg/m2

Waist to hip ratio should be measured, in men more than 1:1 and women more than 0:8 is considered significant.

Further evaluation studies like skinfold thickness, bioelectric impedance analysis, CT, MRI, DEXA, water displacement, and air densitometry studies can be done.

Treatment / Management

Obesity causes multiple comorbid and chronic medical conditions, and physicians should have a multiprong approach in the management of obesity. Practitioners should individualize treatment, treat underlying secondary causes of obesity, and focus on managing or controlling associated comorbid conditions. Management should include dietary modification, behavior interventions, medications, and surgical intervention if needed.

Dietary modification should be individualized with close monitoring of regular weight loss. Low-calorie diets are recommended. Low calorie could be carbohydrate or fat restricted. A low-carbohydrate diet can produce greater weight loss in the first months compared to low-fat diet. The patient's adherence to their diet should frequently be emphasized.

Behavior Interventions: The USPSTF recommends obese patients to be referred to intensive behavior interventions. Several psychotherapeutic interventions are available which includes motivational interviewing, cognitive behavior therapy, dialectical behavior therapy, and interpersonal psychotherapy. Behavior interventions are more effective when they are combined with diet and exercise.

Medications: Antiobesity medications can be used for BMI greater than or equal to 30 or BMI greater than or equal to 27 with comorbidities. Medications can be combined with diet, exercise, and behavior interventions. FDA-approved antiobesity medications include phentermine, orlistat, lorcaserin, liraglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, phendimetrazine. All the agents are used for long-term weight management. Orlistat is usually the first choice because of its lack of systemic effects due to limited absorption. Lorcaserin should be avoided with other serotonergic medications due to the risk of serotonin syndrome. High responders usually lose more than 5% weight in first three months.

Surgery: Indications for surgery are a BMI greater or equal to 40 or a BMI of 35 or greater with severe comorbid conditions. The patient should be compliant with post-surgery lifestyle changes, office visits, and exercise programs. Patients should have an extensive preoperative evaluation of surgical risks. Commonly performed bariatric surgeries include adjustable gastric banding, Rou-en-Y gastric bypass, and sleeve gastrectomy. Rapid weight loss can be achieved with gastric bypass, and it is the most commonly performed procedure. Early postoperative complications include leak, infection, postoperative bleeding, thrombosis, cardiac events. Late complications include malabsorption, vitamin and mineral deficiency, refeeding syndrome, dumping syndrome.[11][12][13]

Pearls and Other Issues

Management of obesity should also include prevention strategies with physical activity, exercise, nutrition, and weight maintenance.

Enhancing Healthcare Team Outcomes

The management of obesity is best done with a multidisciplinary team that includes a bariatric nurse, surgeon, internist, primary care provider, endocrinologist, and a pharmacist. The key is to educate the patient on the importance of changes in lifestyle. No intervention works if the patient remains sedentary. Even after surgery, some type of exercise program is necessary to prevent weight gain. So far there is no magic bullet to reverse obesity- all treatments have high failure rates and some like surgery also have life-threatening complications. Lifestyle changes alone can help obese people reverse the weight gain, but the problem is most people are not motivated to exercise.[13][14]

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A 17-year-old female comes for a routine physical exam. She is obese and her body mass index (BMI) is in the ninety-sixth percentile according to her growth chart. What is the best recommendation for the family and patient?

She is obese and is at an increased risk of developing diabetes mellitus type 2 if she does not reduce her BMI

She is overweight but otherwise healthy

She likely had a growth spurt, so she can be reweighed in 6 months

She needs to be placed on a bowel cleansing regimen to rid her body of excess fat

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While examining a 14-month-old boy, one notices that his weight is in the 95th percentile and his height is in the 50th percentile. When discussing the implications of maintaining a healthy weight, and the mother says that she is very proud of her son's size. The response to her should be guided guided by what understanding?

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The benefits of exercise on the prevention of diabetes mellitus and decreasing the risk of heart attacks

The benefits of exercise on decreasing depression

The benefits of exercise on improving endurance and walking speed

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Gastric bypass results in sustained weight reduction less than 10% of the time

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Lifestyle changes including nutrition and exercise will not cause weight loss

About one third of all adults in the US are obese, defined as a BMI>30

Surgical treatment is ineffective

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A nurse is educating a client about the risks associated with obesity while on a clinical rotation at a wellness clinic. The nurse discusses the complications related to continued weight gain. What potential complication of obesity should be included in the teaching session? Select all that apply.

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Obesity - References

References

Saalbach A,Anderegg U, Thy-1: more than a marker for mesenchymal stromal cells. FASEB journal : official publication of the Federation of American Societies for Experimental Biology. 2019 Feb 27; [PubMed]

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